Pultorak, Stanley rrO'74N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director `f) ,/VA y
Name eTt n lj 1 V-� ��1�C�Rfl Case# 1
Date Of Cremation 9 - 1 — 2lJd
Time Cremation Started C) L] n �✓�
Time Cremation Completed
Type of Container(3,V-4 120 ALI 7 b L-1 J/ K)- -A
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Cieinatonu►n. in accordance with and subject
to its Rules and Regulations to cremate the remains of:
J&Z:� C/. P-14-z� "� ,
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on ems—day of Azr 20 l3
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Aol
Relationship to deceased
Name of Funeral Home n '1&11 —
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims or deman s are or are not wholly groundless, false or fraudulent.
7 �
(WIT E S) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
0�
SULU VAN-NMUHAN POD FUN="BOPAX
407DqRAW
Qwwwbom NY 12804
(516)79 -2W7 •
"Customer's Designation of Intentions"
Name of Deceased.: sr-�_ %y' '%� --+✓ -!' R.!c.
Cremation: . l y I, e 3
(Scheduled Date) (Location)
Manner of Dispoition off/Cremated.Remains:
Burial at ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to eceased)
n�
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
cremation may be disposed of by this firm by place ent in a columbarium."
Printed Name of Funeral Director y Sign of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated. Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.V96